Friday, 17 January 2014

Life would be unmanageably
complex if we were not able to organise aspects of our environment and
experiences into categories. Sometimes
categories and labels are imposed on us, e.g. gender, race and in some cases “class”,
and can be a burden as much as an aid. But many are more fluid and can be
organised (and re-organised) according to personal preferences. If you've ever tried
to prepare a meal in someone else’s kitchen, for example, you will have seen
that the way they group and organise utensils, appliances and crockery might be
very different from the system that works so well for you at home. One is not necessarily
superior to the other, but your system no doubt makes sense to you, as does
your friend’s to him or her. Sometimes we are inspired by other people’s ways
of organising a particular space or process and we “borrow” systems that look
like they will make our own lives easier.

In its own way,
this process of “working out what goes where” is not much different from the
science of classification of illnesses and disease (“nosology”). Nosology has been particularly important in psychology
and psychiatry, because these disciplines, more than others in the clinical
sciences, rely on clinician judgement about “what goes where”. Conditions such
as schizophrenia and bipolar disorder, for example, are diagnosed not on the
basis of blood tests or radiological scans, but through the process of pattern recognition by skilled and
experienced clinicians. Pattern recognition, as the name suggests, involves a
clinician carefully identifying what might seem like disparate clinical features
(e.g. gradual social withdrawal, expression of “strange” ideas, and lack of sleep
over many days) and asking if they have a likely unifying basis. This kind of
thinking is sometimes referred to as applying Occham’s Razor,
and is designed to protect against blinkered clinical reasoning and confirmatory bias in
the process of differential diagnosis. An inexperienced clinician, for example,
who placed undue significance on one of the features mentioned above (e.g. lack
of sleep), could make a grave diagnostic error and is unlikely to develop an
appropriate management plan.

For many decades
(but not uncontroversially!) the diagnostic systems used to assist in
psychiatric decision-making have been the Diagnostic and Statistical Manual of
the American Psychiatric Association (the so-called “DSM”, now in its 5th
edition, as of 2013) and the World Health Organization’s International Classification
of Diseases (now in its 10th edition, as of 2010, with the 11th
edition due in 2015). The fact that the revision process for DSM-5 took many
years and continues to be the subject of vigorous debate about what is “in” (e.g.
some new categories, such as hoarding disorder), what is “out” (so-called
Asperger’s Syndrome has been removed from this latest edition), and what has
had its diagnostic criteria modified (e.g. substance abuse). As knowledge about
and attitudes towards different conditions evolve, so too do the classificatory
systems that sit around them.

If you’re still
with me at this point, you would be forgiven for thinking that this post is
about how language and learning disorders are treated in DSM-5, released last
year. That is an important and relevant
issue, for speech language pathologists, psychologists, teachers, and parents
alike, and if you’d like to know more about it, you can check out this ASHA
Quick Guide. But no, I’d like to talk instead about the problems that occur
when language and literacy are uncoupled from each other, conceptually,
diagnostically, and educationally.

“Literacy is parasitic on language”

You probably
haven’t thought of literacy as a “parasite” before – it’s certainly an
evocative mental image. I first encountered this term when it was used in a
paper by Professors Maggie Snowling and Charles Hulme in 2012*. Without being too distracted by the microbiological
features of a parasite, this analogy invites us to think about the symbiotic
relationship between language and literacy, and the reliance of literacy on its
“host”, i.e. a child’s underlying expressive and receptive oral language skills.
With respect to the science of classification and its implications for language
and learning difficulties, Snowling and Hulme made a persuasive case in this
paper for what they referred to as “homotypic
comorbidity” between language disorders and reading difficulties. This term draws on arguments in a 1991 paper by Carron and Rutter**, who referred (in relation to the diagnostic classification process of childhood disorders more generally) to the idea that in some cases "....one disorder constitutes an early manifestation of the other" (p.1071).

The term "homotypic comorbidity" will
be unfamiliar to many I suspect (it was to me), but I am sure that with some
reflection, it will enhance the way we understand the relationship between
language disorders and learning problems. I think of it this way:

In the
pre-school years, there’s a sizeable proportion of children (estimates vary for
a range of reasons, but let’s say for argument’s sake 20%) whose oral language
skills (expressive and receptive vocabulary, syntactic complexity, phonemic
awareness, narrative skills) are not developmentally at the point that will
readily support their transition to literacy (biologically a much more “unnatural”
process than talking and listening). Few such children will have been fortunate
enough to have their oral language difficulties identified prior to school
entry, but at some point in the first one or two years of school, a significant
proportion will be identified as having “learning difficulties” (or some variant
of that label), because they are not achieving benchmarks with respect to early
reading and writing skills. Is this likely to be a “new” problem that had no
antecedents in the child’s earlier development? Maybe; in some cases. But in
most cases, what is manifest at school is the surface representation (reading
and writing problems) of an underlying but unidentified, language difficulty
(or “impairment”, or “disorder”, or “deficit”…..that’s another whole debate!).

So the notion of
homotypic comorbidity asks us to apply Occham’s Razor in the process of
classifying and organising children’s early language and literacy difficulties,
and to employ the process of pattern recognition in thinking about children who
struggle to cross the bridge to literacy. It reminds us that learning how to
read is a linguistic task, so we need
to think sequentially about what we are asking children to do with their
emergent linguistic skills at different developmental stages. In the pre-school
years, we ask the child to converse, tell and listen to stories, ask questions,
sing songs, recite silly rhymes, follow instructions and so on.

But on school
entry, we are asking the child to shift their language use from talking and
listening to now take in another symbolic code - reading and writing as well. If we didn’t know that a particular
child had underlying language difficulties on school entry, s/he is likely to
be labelled as having a “learning disorder” (or similar).

Failing to consider
the developmental drivers of a successful transition to literacy poses serious
threats, at two levels: (i) the application in early years classrooms of evidence-based direct
instruction literacy teaching methods that focus on phonological and phonemic
awareness, and (ii) the identification of children who need specialist services
in the early years because of underlying language difficulties.

So – parasitic
relationships are not necessarily to be eschewed, they just need to be
understood. Perhaps language and literacy might be better described as being “co-dependent
best friends”.

*Snowling, M, & Hume, C. (2012).
Annual Research Review: The nature and classification of reading disorders. A
commentary on proposals for DSM-5. The Journal of Child Psychology and
Psychiatry, 53, 593-607.

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A blog on child and adolescent language, language competence and social disadvantage, early literacy instruction, youth offending, communication skills and the student doctor....and a few other bits and pieces.

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About Me

I'm a Professor and Head of the La Trobe Rural Health School and live and work in Bendigo, central Victoria. My research passion is language and literacy competence - primarily as this pertains to vulnerability in early life.
Views expressed on this blog are my own.
I have recently published a book (released by J&R Publishing in March 2017) with Dr Caroline Bowen:
Making Sense of Interventions for Children with Developmental Disorders. A Guide for Parents and Professionals.
http://www.jr-press.co.uk/making-sense-of-interventions-for-childrens-developmental-disorders.html
Australian orders can be placed at:
http://www.sandpiperpublications.com.au/Making-Sense-of-Interventions-scp100568.html